Embracing Diversity: Advancing Transgender Mental Health in Nepal

The understanding and recognition of transgender identities have evolved over time and reflected in changes to diagnostic classifications.

The understanding and recognition of transgender identities have evolved over time and reflected in changes to diagnostic classifications.Transsexualism was first introduced in the DSM-III in 1980 and subsequently included in the International Classification of Diseases (ICD-10) by the World Health Organization.1However,diagnostic terminology has evolved to reflect a more clear understanding of gender identity.In DSM-IV, "gender identity disorder in adults and adolescence" replaced transsexualism, while DSM-5 introduced the term "gender dysphoria" in 2013, aiming to destigmatize transgender identities.Notably, the DSM-5 explicitly states that gender non-conformity is not in itself a mental disorder, recognizing the importance of distinguishing between gender diversity and mental health conditions. 2

Conceptual Framework:
Understanding of various terms related to sex and sexuality is essential for promoting inclusivity and respect for diverse identities.Sex is assigned at birth typically refers to biological characteristics, while gender encompasses a broader spectrum of attitudes, feelings, and behaviors associated with one's identity.Gender identity, influenced by environmental, social, and biological factors, refers to an individual's deeply-felt sense of being male, female, or something else, which may not align with their assigned sex.This misalignment can lead individuals to identify along the transgender spectrum.Sexual orientation, on the other hand, pertains to the sex of those to whom one is sexually and romantically attracted.The term "cisgender" describes individuals whose gender identity and expression align with their sex assigned at birth, distinguishing them from transgender or gender nonconforming individuals.Meanwhile, the gender binary concept asserts that there are only two genders, male and female, overlooking the diversity of gender identities.Nonbinary individuals identify outside of this binary structure, and genderqueer individuals reject the binary understanding of gender entirely, identifying with neither strictly male nor female genders.Understanding and respecting these diverse identities fosters a more inclusive and affirming environment for all individuals. 3,4

Mental Health Disparity and Contributing Factors:
Research consistently demonstrates that transgender and gender diverse (TGD) individuals experience higher rates of mental health disorders compared to their cisgender counterparts.Prevalence rates of depressive symptoms, suicide attempts, and self-harm behaviors among transgender youth have been alarming.5Similarly,studies focusing on transgender adults have reported elevated rates of mood and anxiety disorders within this population.Furthermore, recent studies have highlighted the prevalence of mental health disorders in TGD individuals, with significantly higher rates of depression (44.1%), anxiety (33.2%), and suicidality compared to cisgender individuals.Additionally, stigma and discrimination contribute to higher levels of stigmatization among TGD individuals. 6,7veral intersecting factors contribute to the mental health disparities experienced by transgender individuals.The Minority Stress Model 8 , proposed by Meyer highlights the role of chronic stress resulting from societal prejudice, discrimination, and stigma in the development of adverse mental health outcomes among marginalized populations, including transgender individuals.Transphobia, enacted through institutional policies and interpersonal stress, exacerbates mental health disparities.Moreover, transgender individuals often face barriers to accessing gender-affirming healthcare services, including hormone therapy and gender-affirming surgeries.9Thelack of access to competent and affirming healthcare providers contributes to delays in gender transition and exacerbates gender dysphoria, thereby impacting mental well-being.Internalized stigma, resulting from societal messages that delegitimize transgender identities, also contributes to negative self-esteem, psychological distress, and maladaptive coping strategies among transgender individuals. 10

Promoting Transgender Mental Health:
Addressing transgender mental health disparities requires a comprehensive approach that addresses systemic barriers to care, promotes inclusive healthcare practices, and fosters supportive environments for transgender individuals.Healthcare policies should prioritize transgender-inclusive practices, including insurance coverage for gender-affirming treatments and mental health services.Moreover, healthcare providers should receive training on transgender cultural competence and affirmative care practices to

Reet Poudel
Consultant Psychiatry and Sexual Medicine, Shree Birendrra Hospital, Chhauni, Kathmandu deliver patient-centered care to transgender individuals.10Community support initiatives, such as transgender support groups and advocacy organizations, play a crucial role in promoting resilience and well-being among transgender individuals.Peer support networks provide a safe space for transgender individuals to share experiences, access resources, and build social connections.Additionally, legal protections against discrimination based on gender identity are essential for creating inclusive environments that affirm the rights and dignity of transgender individuals. 7,11ntext of Nepal: In Nepal, there are an estimated 900,000 TGD individuals navigating a complex landscape of cultural, social, and economic factors impacting mental health.According to the 2011 census, only 1,500 people in Nepal identified as "third gender."Despite legal reforms recognizing transgender rights, challenges persist in accessing affirming healthcare services and combating societal stigma.
It is imperative for mental healthcare providers to assume a proactive role in addressing the mental health needs of TGD individuals in Nepal, given the scarcity of open discussions surrounding mental and sexual health issues. 12Unfortunately, there are few clinicians practicing in sexual health 13 , and healthcare providers often lack adequate training on transgender issues. 14Psychiatrists, positioned uniquely to address both sexual health and mental health concerns, should prioritize this aspect of mental healthcare.
In conclusion, transgender mental health disparities are complex and multifaceted, influenced by societal attitudes, access to healthcare, and individual experiences of stigma and discrimination.Efforts to address these disparities require a comprehensive approach, including policy changes, increased access to affirming healthcare services, training of healthcare professionals, community support initiatives, and legal protections against discrimination.In Nepal, as in other parts of the world, addressing transgender mental health requires collaborative efforts from healthcare providers, policymakers, community organizations, and individuals to create inclusive environments that affirm the rights and dignity of transgender individuals.